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S5 - Regional/OB - Test 2 > C Section vs. Regional > Flashcards

C Section vs. Regional Flashcards

1
Q

Most common Indications for C section (4)

A
  • previous C section ( #1 cause)
  • dystocia
  • malpresentation
  • non-reassuring fetal status
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2
Q

Indication and benefit for midline vertical skin incision

A
  • “super STAT emergencies”
  • Provides faster and better surgical exposure/ visualizations
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3
Q

Benefits of Horizontal suprapubic skin incision

A
  • you can wear a bikini ( cosmetics )
  • better wound strength
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4
Q

Indications for Verticle uterine incision (5)

A
  • lower uterine segment underdeveloped (<34wks)
  • delivery of preterm infant in a parturient who has not labored
  • multiple gestation
  • malpresentation
  • low lying anterior placenta previa
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5
Q

Uterine Exteriorization risks/cons (5)

A
  • higher rate of N&V
  • increased risk of venous air embolus
  • increased pain
  • controversial effects on blood loss and infection
  • chest pain
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6
Q

Number one complication of C-section

A

Hemorrhage

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7
Q

Complications of C section (7)

A
  • hemorrhage
  • infection
  • thromboembolism
  • ureteral and bladder injury
  • abd pain (i feel like this goes without saying but whateves)
  • uterine rupture in subsequent pregnancies
  • death
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8
Q

Does neuraxial anesthesia increase the rate of cesarean deliveries

A

nah

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9
Q

Can adequate labor analgesia help avoid cesarean deliveries

A

yup

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10
Q

Breech position occurs in what % of singleton pregnancies

A

3-4%

this is dumb but I aint taking any chances this time around

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11
Q

Why should vaginal breech delivery be done with extreme caution?

A

increased risk of emergency section and neonatal injury

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12
Q

Neuraxial anesthesia improves the success rate of ECV by __% w/o increased rate of fetal distress

A

50%

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13
Q

When is ECV typically performed

A

36-37 weeks

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14
Q

What contributes to the likelihood of successful ECV (5)

A
  • normal weight
  • normal amniotic fluid volume
  • presenting part not yet in pelvis
  • fetal back is not posterior
  • frank breech or transverse position
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15
Q

Common complications of ECV

A
  • transient or persistent FHR abnormalities
  • vaginal bleeding
  • placental abruption
  • emergency c section
  • still birth
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16
Q

What block will improve the success rate of ECV

A

high T6-T4 dense neuraxial block

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17
Q

For ECV neuraxial what determines SAB v. epidural?

A
  • SAB if pt to discharge
  • epidural if planning to labor
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18
Q

Intrauterine Resuscitation components (6)

A
  • optimize maternal position
  • oxygen
  • rapid IV bolus of non-dextrose fluids
  • treat hypotension with ephedrine or phenylephrine
  • discontinue Pitocin
  • consider starting tocolytic
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19
Q

What should be included/asked about in pre-anesthetic evaluation for pregnant ppl?

A
  • history (diabetes, preeclampsia)
  • previous pregnancies & any complications
  • MH susceptibility for mom and dad
  • epidural history
  • birth plan
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20
Q

When should anesthesia evaluation ideally occur

A

late 2nd or early 3rd trimester for high risk patients

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21
Q

What are the most common sources of influence to a mother in regards to labor analgesia

A

-friends, family, and Facebook bby

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22
Q

Should you inform your patient with language they understand and can comprehend

A

no shit MBG

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23
Q

Threshold elements of informed consent

A

the patient is competent (able to make sound medical decisions for themselves)

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24
Q

Information elements of informed consent

A
  • provider discloses information about material risks
  • patient understands information
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25
Q

consent elements of informed consent

A
  • provider offers information in a noncoercive manner
  • patient gives authorization voluntarily
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26
Q

How often should maternal BP be cycled?

A

at least q5min

q2 mins after spinal

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27
Q

Should blood admin consent be included in the informed consent discussion?

A

yup

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28
Q

Order of blood loss from vag, c sec, c sec during labor from most to least

A

C-section during labor >> uncomplicated/planned C-section > uncomplicated vaginal delivery

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29
Q

healthy patients for elective c section may drink modest amounts of clear fluids up to __ hrs prior to induction

A

2 hrs

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30
Q

What is more important than volume in regards to aspiration prophylaxis in preggos

A

absence of particulates

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31
Q

How long should ingestion of solid foods be avoided in laboring patients

A

6-8hrs

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32
Q

Sodium citrate has what effect on pH

A

increases it

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33
Q

H2 receptor antagonists, PPIs, and metoclopramide help reduce the likelihood of aspiration by?
What is the onset time?

A

reducing gastric acid secretion and volume

30-40min

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34
Q

how soon is it recommended to begin a narrow-spectrum antibiotic after the start of a c section

A

within one hour

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35
Q

What antibiotic is often used for c sections

A

first-generation cephalosporin

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36
Q

If the patient has a beta-lactam allergy what antibiotic is used

A

clindamycin and gentamycin

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37
Q

When should higher dose antibiotics be considered

A
  • BMI >30
  • absolute weight > 100kg
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38
Q

It is okay to administer low dose benzo to help with anxiety

A

yes, may aid in neuraxial technique, lessen the risk of PTSD, and low doses have minimal to no effect on baby

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39
Q

After how many weeks gestation should all mamas be placed in left uterine displacement

A

20 weeks gestation

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40
Q

What position may help reduce the incidence of hypotension after initial hyperbaric spinal analgesia

A

slight (10 degree) head-up position

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41
Q

What position can significantly improve FRC

A

head up 30 degrees

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42
Q

What position may augment venous return and cardiac output but also may result in more cephalad spread of anesthesia

A

Trendelenburg

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43
Q

Which position for neuraxial minimizes the prominence of dural sac and decreases the severity/duration of hypotension

A

lateral position

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44
Q

When should sitting position for neuraxial insertion not be used?

A
  • fetal head entrapment
  • umbilical cord prolapse
  • footling (?) breech presentation
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45
Q

Potential benefits of supplemental oxygen with neuraxial

Is it currently still recommended

A
  • better oxygenation (shocker)
  • better umbilical cord acid-base balance
  • less time to sustained respiration of neonate

unclear, seems dumb. conflicting research

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46
Q

Indications for Neuraxial Anesthesia(4)

A
  • mother request
  • difficult airway or aspiration risk
  • comorbidities
  • GA intolerance
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47
Q

Benefits of neuraxial anesthesia

A
  • can utilize neuraxial analgesia after surgery
  • less fetal drug exposure
  • less blood loss
  • allows the presence of support person
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48
Q

Indications for GA

A
  • maternal refusal/uncooperative with neuraxial
  • contraindications to neuraxial (coagulopathy, site infection, LA allergy)
  • sepsis
  • severe hypovolemia
  • intracranial mass with increased ICP
  • fetal issues
  • not enough time for neuraxial
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49
Q

Advantages of epidural

A
  • no dural puncture is required
  • ability to titrate
  • continuous post-op analgesia
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50
Q

disadvantages of epidural

A
  • slow onset
  • larger dose required
  • greater risk of toxicity and for fetal exposure
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51
Q

advantages of CSE

A
  • technically easier in obese than spinal
  • low dose
  • rapid onset of dense block
  • ability to titrate
  • continuous intra-op anesthesia
  • continuous post-op analgesia
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52
Q

disadvantages of CSE

A

delayed verification of functioning epidural

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53
Q

One shot spinal advantages

A
  • low dose
  • fast onset of dense lumbosacral and thoracic anesthesia
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54
Q

one shot spinal disadvantages

A
  • limited duration
  • unable to titrate extent of block
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55
Q

continuous spinal advantages

A
  • low dose
  • rapid onset of dense block
  • titratable
  • continuous intraop anesthesia
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56
Q

continuous spinal disadvantages

A
  • larger dural puncture increases the risk of PDPH
  • possibility of overdose and total spinal
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57
Q

What is the most common anesthesia technique for C section

A

Spinal Anesthesia (SAB)

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58
Q

Which bevel is rarely used and associated with a higher incidence of PDPH

A

Cutting bevel

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59
Q

Which bevels are almost exclusively used

A

non-cutting ( “pencil point”)

Sprotte or Whitacre (Won’t Shear) :)

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60
Q

Larger or smaller needles are more likely to withstand high resistance without damage?

A

larger needles

61
Q

Introducer needles are necessary for larger needles, smaller needles, or both?

A

smaller only

62
Q

Which SAB approach is typically less painful for the patient

A

Midline approach

63
Q

Which SAB approach is typically faster

A

Midline

64
Q

Which approach requires more patient cooperation with positioning

A

Midline

65
Q

With the paramedian approach are you still trying to puncture the dura at the midline

A

yup

66
Q

are lower doses of central blocks used for pregnant v. nonpregnant patients? Why?

A

yes

-smaller CSF volume, greater sensitivity, cephalad movement

67
Q

What LA is the predominant agent for SAB for Cesarean delivery

A

Bupivicane

68
Q

Bupivacaine dose range

*from chart on slide 49

A

7.5-15mg

69
Q

Bupivacaine SAB duration

*from chart on slide 49

A

60-120min

70
Q

fentanyl dosing for SAB

*from chart on slide 49

A

10-25 mcg

71
Q

fentanyl duration as SAB adjuvant
*from chart on slide 49

A

180-240min

72
Q

benefits of opioid admin with SAB

A
  • improve comfort intra-op and postop
  • decreases need for intra-op opioids
73
Q

Is 20mcg of fentanyl superior to 4mg of ondansetron in the prevention of intra-op vomiting during cesarean

A

yup

74
Q

T/F - Fentanyl as an adjuvant agent in a spinal block leads to increased need for postop opioids after 4 hours

A

False -
Increased need after 6 hours
(Reworded this to make it tricky bc she loves stupid numbers)

75
Q

Advantage of small dose (15-35mcg) vs. large dose fentanyl(45-65mcg) as an adjuvant to a spinal block

A

decreased pruritus, nausea, and vomiting in a SMALLER dose

76
Q

which SAB adjuvant is more effective for prolonged postop analgesia - fentanyl or preservative-free morphine?

how long is analgesia provided?

A

morphine - 12-24 hours

77
Q

T/F occurrence of pruritis with preservative-free morphine in a SAB is NOT dose-dependent

A

false, it is dose-dependent

78
Q

is N/V associated with preservative-free morphine dose-dependent

A

nope

79
Q

Purpose of adding dextrose to SAB

A

make a hyperbaric solution

80
Q

purpose of adding epi to SAB

A
  • increases density of motor blockade
  • may prolong the duration
81
Q

benefits of adding clonidine to SAB (3)

A
  • improves analgesia
  • decreases shivering
  • reduces peri-incisional hyperalgesia
82
Q

Black box warning for spinal clonidine in OB patients

A

bc of concerns with hemodynamic instability

**given anyways, so don’t let her trick you on the next test **

83
Q

Neostigmine use in SAB has shown a decrease in postop pain BUT what negative side effect limits its usefulness

A

nausea

84
Q

How does neostigmine in SAB affect FHT or Apgar scores?

A

it doesn’t

85
Q

Why is the use of epidural anesthesia for elective cesarean delivery becoming less common (4)

A
  • block less reliable
  • higher doses (5-10 times)
  • greater systemic absorption increases risk of LA toxicity
  • slower onset
86
Q

most common LA for initiation and maintenance of epidural for cesarean

A

2% Lidocaine with epi

87
Q

Which LA results in the most rapid onset and shortest duration

A

3% 2-chloroprocaine

88
Q

which LA is associated with rapid onset of hypotension and reduced clinical efficacy if administered with opioids

A

3% 2-chloroprocaine

89
Q

Can you add fentanyl, sufentanil, clonidine, neostigmine, or epi to an epidural?

A

yup

*she provided no life-changing info on how the effects of these being added to an epidural is any different from a spinal. she listed the same things so see book decks for more info (hopefully)

90
Q

when is the use of epi in an epidural controversial

A

preeclamptic women

91
Q

the benefit of adding sodium bicarb to epidural

A
  • more non-ionized molecules, speeds onset
  • improves quality
92
Q

Combines the rapid and predictable onset of a spinal with the ability to titrate with the epidural catheter

A

Combined spinal-epidural (CSE) anesthesia

93
Q

Extension of a T10 level of analgesia to T4 level anesthesia requires how much local with one or more adjuvants

A

15-20ml

94
Q

how does the prep and drape process for a c section differ from general abdominal surgery?

A

prep and drape occurs BEFORE induction of GA

95
Q

What type of induction is required for all preggos

A

RSI following preoxygenation

96
Q

what is typically used for induction (agent + dose) in cesarean GA cases

A

propofol 2-2.8mg/kg

97
Q

in the case of hemodynamic instability what agent(s) are typically substituted for propofol

A

Ketamine 1-1.5mg/kg
Etomidate 0.3mg/kg

98
Q

Which NMBs and dose are used for induction

A

Succinylcholine 1-1.5mg/kg
Roc 1mg/kg

99
Q

What size ETTs are typically used to intubate pregnant women

A

6-6.5 with semirigid stylet

100
Q

If an airway is difficult should you follow the difficult airway algorithm

A

i know this is SHOCKING, but yes

101
Q

Indications for GA

A
  • coagulopathy
  • infection at the insertion site
  • sepsis
  • severe hypovolemia
  • known allergy to LA
  • intracranial mass with increased ICP
  • failure of neuraxial technique
  • fetal issues
  • inefficient time for neuraxial

*THE SAME EFFING LIST SHE PUT IN HERE LIKE 5 TIMES but here it is again folks

102
Q

ETCO2 goal for a pregnant momma during GA

A

30-32mmHg

103
Q

Excessive ventilation of pregnant mom can cause uteroplacental vasoconstriction and shift the oxyhemoglobin dissociation curve to the __

A

to left to the left

104
Q

Is there a particular inhalation agent preferred for GA for cesarean

A

nope, none are superior to others for these cases

105
Q

what MAC may reduce the effect of oxytocin on uterine tone > blood loss

A

1-1.5 MAC

106
Q

When are opioids typically delivered during GA cesarean

A

given after the cord is clamped

107
Q

adverse effects of U-D interval longer than 180 seconds

A

lower Apgar scores and fetal pH

108
Q

How long postpartum are women considered full stomachs

A

6 weeks postpartum

109
Q

position for emergence and extubation

A

semirecumbent

110
Q

majority of deaths with GA due to what during emergence

A

hypoventilation or airway obstruction

111
Q

Does thiopental cross the placenta?

A

yuppp

112
Q

Do induction doses of thiopental 4mg/kg achieve fetal brain threshold for neonatal depression

A

rarely, but large doses 8mg/kg can

113
Q

what allows for the mother to be unconscious and the neonate be awake when thiopental is used (4)

A
  • preferential uptake of thiopental by the fetal liver
  • higher relative water content of the fetal brain
  • rapid redistribution to maternal tissues
  • nonhomogeneity of blood flow in intervillous space
  • progressive dilution by admixture with various components of fetal circulation
114
Q

Does propofol result in higher or lower Apgar scores compared to thiopental

A

lower

115
Q

what induction agent has a higher incidence of maternal hypotension

A

propofol

116
Q

does propofol cross the placenta

A

yup

117
Q

Which agent should you choose for urgent deliveries in a patient with hypotension or acute asthma exacerbation

A

Ketamine due to its sympathetic properties

118
Q

When is ketamine not recommended

A

preeclampsia

119
Q

the use of etomidate as an induction agent is ideal for what situations (2)

A
  • hemodynamic instability
  • severe CV disease
120
Q

What effect does etomidate have on neonatal cortisol production

A

transient reduction

121
Q

side effect associated with the use of etomidate

A

nausea and vomiting

122
Q

why is versed often avoided

A

amnestic properties

123
Q

dose of succs to intubate mom

A

1-1.5mg/kg

124
Q

intubating conditions in how many seconds after sux

A

45seconds

125
Q

does sux cross the placenta

A

only trace amounts

126
Q

What dose of sux would allow for placenta transfer and result in sufficient fetal weakness

A

10mg/kg

127
Q

Roc dose

A

0.6mg/kg = ideal intubating conditions in ~79 seconds (eye roll)

also has 1 mg/kg in this ppt? so in conclusion, unclear

128
Q

ideal intubating conditions in how many seconds after 0.6 mg/kg roc

A

79 seconds

129
Q

does roc have an effect on Apgar scores

A

no

130
Q

Vec dose

A

0.1mg/kg

131
Q

Vec onset

A

144seconds

132
Q

Why is atracurium a less desirable agent for RSI (3)

A
  • high doses required
  • histamine release
  • hypotension
133
Q

What effect does nitrous have of maternal BP

A

minimal

134
Q

What effect does nitrous have on uterine tone?

A

minimal

135
Q

does nitrous cross the placenta

A

yup

136
Q

what is seen more often in neonates when exposed to nitrous

A

need for resuscitation

137
Q

what effect do volatiles have on the uterine tone

A

decreases

138
Q

At what MAC are oxytocin-induced contractions completely inhibited

A

2 MAC

139
Q

metabolite for meperidine

A

normeperidine

140
Q

effect of the build-up of normeperidine

A
  • can build up in both mother and baby
  • results in respiratory and neurobehavioral alterations
141
Q

MH is what kind of inherited gene

A

inherited autosomal dominant

142
Q

Is malignant hyperthermia more prevalent in the pregnant population

A

nope, v v rare

143
Q

When is oral intake recommended post-cesarean

A

within 4-8hrs

144
Q

Risk factors for urinary retention (3)

A
  • post-op opioid analgesia
  • multiple gestation
  • low BMI
145
Q

Symptoms of high neuraxial block (5)

A
  • impaired phonation
  • unconsciousness
  • respiratory depression
  • bradycardia
  • hypotension
146
Q

Does prewarming before neuraxial help limit the reduction in temp

A

epidural- yes
spinal - no

147
Q

When is the pregnant patient at highest risk for developing an embolus

A

the first week postpartum

148
Q

prophylaxis for embolus (4)

A
  • hydration
  • early mobilization
  • pneumatic compression devices
  • pharmacologic in high-risk patients
149
Q

benefits of horizontal uterine incision (4)

A
  • less incidence of uterine rupture
  • lower infection risk
  • decreased blood loss
  • decreased risk for adhesions

S5 - Regional/OB - Test 2 (9 decks)

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